Parent/Carer Declaration Form – Summer 2016

Two, three and four year old Free Early Education Entitlement

  • For all children born between 01/04/2011and 31/03/2013
  • For children born between 01/04/2013 and 31/03/2014 where Two Year Old Funding has been approved
  • To be completed in partnership between the parent/carer and early years provider
  • Please complete the form clearly
  • By completing and signing this declaration you are entering into a contractual agreement for the entire summer 2016 term. Full details can be found online at

Setting details
Name of childcare provider
Ofsted registration number
Child’s details
Forename(s) / / Gender / Male / Female
Surname / / Date of birth
Child’s address
Postcode
Early Years Pupil Premium for 3 and 4 year olds (to be completed by eligible parent)
Tick here if you have checked eligibility and they are not eligible (no need to complete this section)
Parent forename / Gender / Male / Female
Parent surname / Date of birth
NI Number / NASS reference
Eligibility criteria (please tick all that apply, or may apply)
Financial criteria
Child has been in local-authority care for one day or more in England and Wales
Child adopted from care in England or Wales or left care under special guardianship or residency order
Free Early Education Entitlement claim
I confirm that my child will receive the following free early education in summer term 2016
Number of funded weeks to be claimed in summerterm 2016 / Funded weeks / Funding start date / Funding end date
Funded hours claimed each day / Monday / Tuesday / Wednesday / Thursday / Friday
Funded hours claimed this term / Provider signature
Does your child attend any other early education provider? If yes, please complete details below
Additional provider - Name
Additional provider - Address
Total hours to be claimed for spring term 2016 at the second provision
Child’s ethnic origin (optional)
White - White British / Asian or Asian British - Indian
White - White Irish / Asian or Asian British -Pakistani
White - Traveller or Irish Heritage / Asian or Asian British -Bangladeshi
White - Gypsy / Roma / Asian or Asian British -Any other Asian background
White - Any other White background / Black or Black British - Black Caribbean
Mixed/dual background - White and Black Caribbean / Black or Black British - Black African
Mixed/dual background - White and Black African / Black or Black British - Any other Black background
Mixed/dual background - White and Asian / Chinese
Mixed/dual background - Any other mixed/dual background / Prefer not to say
Any other ethnic group (please specify)
Privacy notice – Young children in Early Education settings in Redbridge
This setting and the London Borough of Redbridge process personal data about children and are “data controllers” in respect of this for the purposes of the Data Protection Act 1998. Your early years setting will provide information to the Council to benefit the development of your child and early years’ provision in Redbridge.
This data includes contact details, child development assessments, attendance information and characteristic such as ethnic group.
The local authority has a statutory duty under Section 1 of the Childcare Act 2006 to ensure that it improves the wellbeing of young children in its area and reduces inequalities between young children.
By sharing some personal and sensitive information and assessment data it helps to support the improvement of services to families with young children and ensure that the local authority can comply with its duty under the Childcare Act 2006 to improve the wellbeing of children and reduce inequality.
The local authority is a data controller in respect of the data they receive, and is subject to the same legal constraints under the Data Protection Act 1998 in how it deals with the data. The information will be held securely and will be destroyed after seven years. This data will only be used for the above purpose and will not be shared unless for specific purposes allowed by law.
Children, as data subjects, have certain rights under the Data Protection Act, including a general right to be given access to personal data held about them by any data controller. Anyone with parental responsibilities can make a request on behalf of a child until the child is at an age of understanding, usually around the age of 12.
Should you wish to opt out, please inform your child’s early years setting.
If you require more information about how the local authority (LA) store and use your information, please visit
To see what information is being held about you or your children by the Local Authority please write to the Data Protection Officer at the following address, providing as much relevant information as you can:
Data Protection Officer, Town Hall, High Road, Ilford, Essex, IG1 1DD
If you would like any further information on the Free Early Education Entitlement for 2, 3 and 4 year olds or Early Years Pupil Premium please contact the Families Information Direct (FiND) Helpline on 0800 587 7500 or email .
Parents declaration
  • I confirm I will be claiming my free early education with the childcare provider(s) named overleaf and for the hours detailed.
  • I have read and understood the Privacy Notice shown above.
  • I understand my child’s early years setting is entitled to charge me for hours attended above and beyond the termly allocation of free early education entitlement, and if I knowingly or fraudulently claim more than my entitlement then I may be liable to refund the London Borough of Redbridge appropriately.

Signature of parent/guardian of child / Date

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